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Massachusetts Reviewing Board Decision Considers Questions of Sufficient Medical Evidence for Payment of Reasonable and Necessary Treatment

Massachusetts workers’ compensation requires insurers to pay for appropriate and necessary treatment under §§ 13 and 30 of the Workers’ Compensation Act for employees who suffer a workplace injury. Since an employee’s medical history can affect whether or not money is paid for a disability, multiple injuries and health conditions can limit or prevent payments for reasonable and necessary treatment. In one of the last Reviewing Board decisions of 2017, the Board assessed whether or not an administrative judge’s order Legal News Gavelfor the insurer to pay expenses under §§ 13 and 30 of the workers’ compensation act was made in error after he refused to allow additional medical evidence during the proceeding.

The employee suffered a repetitive motion workplace injury to her left elbow in 1997. The woman underwent two unsuccessful operations in 1997 and 1998, which caused nerve damage and enduring pain in her left arm. In 1999, she received a lump sum for the injury, entering into an agreement with the insurer, which agreed to pay for reasonable, necessary related medical expenses. A year after this agreement, she began taking Fentanyl and Vicodin to help manage pain.

Between the agreement and the proceeding, the injured employee earned an advance degree and returned to work for a different employer. In 2009, she broke two toes and sprained her ankle in an accident unrelated to work, developing Reflex Sympathy Dystrophy (RSD) in her right leg. For this, she was prescribed Fentanyl, Vicodin, and Lyrica for pain. Between 2010 and 2015, her health insurer paid for these medications.

The employee filed a claim against the insurer for the §§ 13 and 30 medical benefits, including the insurer of her current employer. The judge initially denied both claims, and the employee appealed. The injured woman removed her claim against the current employer’s insurer and moved forward with the questions of whether her prescriptions were causally related to the workplace accident long ago, whether they were reasonable, and whether they were necessary.

The employee was seen by the independent medical examiner (IME), as required by the workers’ compensation statutes. The insurer was displeased with the report, requesting additional medical evidence because the IME was not a pain specialist but a board certified orthopedist. The judge denied the motion, adopting the findings of the IME, who testified the medications were reasonable and necessary for treatment of the 1997 injury. The insurer appealed, arguing the impartial opinion was inadequate as a matter of law.

The Reviewing Board agreed with the insurer, stating the judge should not have prevented the inclusion of additional medical testimony. The Board felt that such testimony was necessary to fairly present the medical issues because the IME acknowledged he was unable to fully address the medical issue at the heart of the claim. The Board looked at several prior opinions, which consistently held ambiguous and confusing opinions from an IME cannot be the only medical evidence in a workers’ compensation claim. The IME first wrote in his report that much of the medication use was a result of the 2009 accident, but he seemingly changed his opinion at a deposition. The IME testified that all three pain medications were prescribed for both the elbow and the foot condition, and they were reasonable for treatment of the elbow pain from the 1997 accident.

In the hearing transcript, the IME repeatedly made statements on his lack of knowledge regarding adequate pain treatment, since he was not a pain specialist. He admitted he did not know what was appropriate treatment on cross examination and deferred to the opinion of another specialist whose report was submitted to him for consideration. The board reversed and recommitted the case to the administrative judge to allow both sides to submit additional medical evidence.

An experienced Massachusetts workers’ compensation attorney understands the type of proof needed to show reasonable and necessary expenses. If you’ve been injured in a workplace accident, contact the lawyers at Karsner & Meehan for help with your claim. For a free, confidential consultation, call 508.822.6600.

More Blog Posts:

Massachusetts Appeals Court Analyzes Spoliation of Evidence in Negligence Action Involving Severe Injuries, December 28, 2017, Massachusetts Injury Lawyers Blog

Massachusetts Workers’ Compensation Reviewing Board Affirms Temporary Total Incapacity Benefits Award to Registered Nurse, November 16, 2017, Massachusetts Injury Lawyers Blog